A blunder which saw a patient waiting in vain for gender surgery they'd never even been referred for has prompted a call for health chiefs to review their procedures around sex change referrals.

The ombudsman made the call after it found that a person waiting for gender realignment surgery had been waiting for more than 12 month expecting a procedure that had not even been scheduled because of a referral not being made properly.

A patient had been seen by a consultant who confirmed they had gender dysphoria. The psychiatrist noted that the patient wanted to be referred to the Gender Identity Clinic to discuss hormone and surgery options, but 12 months later when the patient’s GP asked if the referral had been made, the doctor found it had not.

In January 2017, the funding for the treatment was authorised, but the patient then learned that the wait would be up to 13 months.

The patient was left “crushed” by the news. And matters were made worse by the fact that when the clinical director of Betsi Cadwaladr University Health Board wrote to the Gender Identity Clinic asking for the appointment to be expedited, they got no reply.

The Public Serve Ombudsman for Wales said there had been “clear injustice”.

Betsi Cadwaladr University Health Board has been ordered to pay £1000 to a gender realignment patient who waited in vain for a procedure they'd not even been referred for

Figures published by Betsi Cadwaladr in July this year detailed there had been 51 initial referrals for people found to be suffering gender dysphoria since June 2016, when the health board began keeping records.

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Of those, nine were refused further referrals along the process after the initial reviews, and none of the nine them appealed the decision.

Investigating officer Maureen Campbell-Taylor said: “I have concluded that the failings, which led to proper administrative processes in terms of the initial referral not being followed, amounted to maladministration.”

She also found shortcomings in the handling of the complaint, which she said had been both “lacking in clarity and muddled”, saying it is unclear whether any failings have been learned from by the health board.

The Board’s Chief Executive Gary Doherty has apologised and the patient is to receive £750 for the distress caused and £250 for the shortcomings in handling the complaint.

The ombudsman report concluded by saying “If it has not already done so, the health board should seek to identify whether other transgender patients may have been similarly affected by the psychiatrist not following the correct referral pathway.”